Lone-Gunman Based Safety

Multiple causes

By Phil La Duke

Ever since Jack Ruby gunned down Lee Harvey Oswald while being transferred from a Dallas police station to county jail debate has raged as to whether or not Oswald acted alone or if he was part of a larger conspiracy. There’s not much satisfaction in the “Lone Gunman” theory; it lacks the panache and high drama of a conspiracy, but beyond that, the Lone Gunman theory seems too simple, too convenient, and too pat. I got thinking about the Lone Gunman theory as it pertains to safety and think the comparison is apt.

I came to realize that most safety professionals see injuries as the result of “Lone Gunman” thinking after listening to yet another argument about the nature of injures. “Injuries are caused by behaviors” “no they’re caused by process flaws” “no they’re caused by…” it sure sounds to me like the people who argue whether or not Oswald acted alone. Sound crazy? Think about it: if you believe that the majority of injuries are caused by a single thing you are essentially dismissing the possibility that worker injuries are caused by a complex situations with multiple and often inter-related cause and effects.

The lone gunman theories are attractive; they boil our problem down to a single factor that we can rigorously attack and solve it. This kind of thinking is satisfying because it means that all we need do is to solve one problem and we don’t have to be distracted by all the other things that may or may not be causing injuries.

Now some reading this will immediately hide behind the fact that they never said that ALL injuries are caused by (fill in the blank) but that MOST injuries are caused by (fill in the blank). That’s a convenient (albeit cowardly) way to stack the deck in your favor but it’s a specious and facile argument, even if we can say with credibility that 99% of injuries are caused by a single cause we have always have that 1% that aren’t and that allows us to dismiss it as an outlier.. Dismissing causes that don’t neatly fit into your view of the world as statistical aberrations or outliers is just another form of calling a fatality an unforeseeable act of God.

No One is So Dangerous as the Man with the Whole World Figured Out

When we start to see any topic with a fanatic’s singularity we become dangerous. If we believe that most injuries are caused by a single cause—whether it be leadership, or culture, or process failures, or human error, or risk taking, or pixies, faeries, and trolls—we create a world where anyone who disagrees must be heretics and heretics must die or at very least publicly mocked behind the walls of anonymity of a LinkedIn discussion thread.

Call Us Legion, For We Are Many

I am distrustful of the “one-size-fits-all” approaches to injury reduction, which let’s face it, isn’t the same as safety and yet many of the programs, snake-oils, and magic bullets our there promise safety and only sometimes deliver injury reduction. It’s dangerous to think in terms of a lone-gunman cause for injuries (even when allowing for the possibility that there could be other lone gunman working simultaneously. The opposite of lone gun thinking is conspiracy theory, which okay, I admit, makes me sound like even more of a whack-job than usual. But for our purposes think of injury causes as being somewhat, or at least potentially, benign by themselves. We interact with hazards every day and in the fast majority of those interactions we don’t get harmed. But the more hazards that are present the greater the probability of injury and the presence of some catalyst causes us to be injured. Think of the straw that broke the camel’s back: up until that last minute the camel was uninjured, but given enough objects loaded onto the camel’s back eventually the camel will exceed its capacity to hold the weight.

There are many things, often working in tandem, that cause injuries and we have to stop arguing over whether the straw broke the camel’s back or whether the man who overloaded the camel was to blame, or whether the camel made poor choices, or whether both camel and man had been poorly trained, or whether we could provide an incentive for the camel’s back not to break and realize that there is seldom only one thing going on, and in most cases hazards work together to achieve a lethal synergy that can maim, cripple, and kill.

We Need To Look for Questions Not Answers

I taught problem solving for many years. One technique we used was called Situation Analysis. This technique is used to solve problems with more than one cause, has inter-related causes and effects, and grew over time. The technique was useful for solving broad problems (like…I don’t know…injuries). What I found interesting is that this technique taught people that if you only focus on one of the causes and ignore the others you won’t really SOLVE the problems you would merely make the symptoms go away until the other causes would cross a threshold causing the problem to return even worse than it had been before. I think of the conundrum of fatalities. Injury rates seem to be going down (although many believe that this is largely the result of under-reporting or more rigorous case management) while fatalities are staying flat or in some cases rising. This is the exact pattern one would expect from methodologies that attack one cause while ignoring others─ the problem seemed to be going away until it roared back worse than ever. It has left safety professionals scratching their heads, but if we attack the lack of safety as a complex problem that has multiple causes that are interrelated we might just be able to manage things better and save some lives.

I’m Not Alone

I know I may sound like a broken record, but when you sell hammers all the world looks like a nail, and while I have heard many say “well BBS is just a tool in my toolbox” (and I use BBS as an example because I hear this more then let’s say “human performance” or “leadership improvement”) I get skeptical. I want to ask what other tools do you use? When do you use them? When is it inappropriate to use them? But I don’t; frankly I’m tired of arguing with fanatics. One bright spot is that I am meeting more and more people who are beginning to think like me. Rockwell, for example, talks about the 3Cs of safety. The 3 C’s are Capital, Compliance, and Culture. Now I’m not here to promote Rockwell but I like where their heads are at on this. I’m over simplifying their spiel here but effectively what they are saying is that you have to consider all three of these things when attacking safety issues. Capital-you have to make capital expenditures to fund projects to improve your equipment. I would expand that to include your facilities as well, but I think their point is well taken. Compliance-let’s not forget that we have to follow the law and that basic compliance is the gateway to more advanced safety solutions. And Culture-hiring qualified organizational development professionals to make substantive changes in how your organization views and values safety is important. To hear Rockwell tell it, you can’t expect great results without looking at all three; I think they are right.

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